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				<p class="content-title">Key Concepts</p>
				
				<ol type="I" class="paragraph">
					<li><strong>Revenue Streams</strong></li>					
					<p class="paragraph">Related organizations derive the generation of their revenues from the following:</p>					
					<ul class="paragraph disc">	
						<li><strong>Healthcare Premium</strong></li>						
						<p class="paragraph"> Premiums are periodic collections done to members in order for them to be enrolled and be covered for 
						a certain benefit package. Depending on the organization (and other regulatory or legislative interventions), 
						rates of premiums may vary based on a function of age, existing health conditions, desired coverage, and the 
						like. With any pre-need organization, premiums are factored in based on actuarial calculation on risks presented 
						by an entity that is covered. In the case of healthcare, the financial risks are spread over a “community” with 
						varying risk level and therefore should be off-set to a level that would most likely sustain operations and
						yield profits.</p>
						
						<li><strong>Treasury</strong></li>
						<p class="paragraph"> A major activity also for Managed Health services to remain profitable is the prudent allocation of any
						financial reserves (i.e. excess funds available after an ample allocation to funds to cover benefit claims) 
						to various investment options.</p>
					</ul>
					
					<li><strong>Benefit Types</strong></li>
					<p class="paragraph">Managed care services should provide for at least one of the following benefit types:</p>
					<ul class="paragraph disc">	
						<li><strong><i>Medical</strong></i> – professional treatment for any injury or illness.</li>
						<li><strong><i>Pharmaceutical</strong></i> – guided services on the provision of drug/medicinal treatment aimed
						to eliminate or reduce the patient’s symptoms on certain medical conditions, or to slow down the progress of a 
						disease, or simply to prevent a disease and the symptoms involved.</li>
						<li><strong><i>Dental</strong></i> – services offered for the teeth, may it be cleaning, whitening, x-ray, 
						fillings, tooth extraction and oral surgery.</li>
						<li><strong><i>Ambulatory Services</strong></i> – services provided to patients outside of the medical facility
						premises. Usually given to patients who have returned home after receiving medical diagnosis or treatment without
						having to stay overnight in the hospital. Outpatient services included are preventive, diagnostic and treatment.</li>
						<li><strong><i>Mental Healthcare Service</strong></i> – services rendered which involves the examination and 
						treatment for people having problems on their psychological state. Services may include individual therapy, group 
						therapy, social care and medication evaluation.</li>
					</ul>
					
					<li><strong>Benefit Coverage Calculation, Limits and Accumulators</strong></li>					
						<strong>Benefit Coverage Models</strong>
						<p class="paragraph">Standard practices for controlling and limiting benefit coverage are implemented (mostly based on country as these 
						are regulated and controlled normally by Government Entities). The following are the currently identified benefit 
						coverage models:</p>
						
						<div class="text-underline"><strong>Maximum Benefit Limit (Philippine Setting)</strong></div><br/>
						<img class="img-responsive center-block" src="../../img/industry-segments-managed-care/max-benefit-limit.png"/>						
						<div class="caption text-center">Figure 1 – Coverage Model: MBL Based (Philippine Setting)</div></br>
						<p class="paragraph">Managed Care organizations in the Philippines set-up and control their benefit coverage using Maximum Benefit Limits.
						In this model, a benefit cap is placed per condition or sickness from which all covered healthcare services in relation 
						to a person’s condition are paid for by the Managed Care Organization until such time that the MBL has been exhausted.
						Note that such limits would reset if a healthcare service is with respect to another condition (unless the condition is 
						caused by a pre-existing condition). Depending on the plan, the coverage may vary based on categories (e.g. In-patient,
						Out-patient), service type (e.g. Dental, Rehabilitative, Pharmaceutical, Medical, etc.), and for some even place additional 
						conditions and restrictions for specialized services (e.g. Fertility, Immunization).</p>
						
						<div class="text-underline"><strong>Accumulator Based (USA Setting)</strong></div><br/>
						<img class="img-responsive center-block" src="../../img/industry-segments-managed-care/accumulator-based.png"/>	
						<div class="caption text-center">Figure 2 – Coverage Model: Accumulator Based (USA Setting)</div></br>
						<p class="paragraph">The US Healthcare Insurance System make use of various accumulators to control consumer behavior (minimize abuse by 
						financially involving consumers on related services). In this model, Deductibles are placed wherein a Member pays in full 
						all related expenses until such a point that a Deductible Limit is met and from which the Insurance Coverage benefits will
						kick-in (point of coverage).</p>
						<p class="paragraph">During said point of coverage, the Member would continue to participate (mostly a smaller portion of a Healthcare
						Service) through a co-insurance and co-pay setting. Co-pays are usually a marginal fixed cost amount. Co-insurance usually
						is a portion of the service cost.</p>
						<p class="paragraph">A member continues to pay co-insurance until such time that an Out-Of-pocket (OOP) limit has been met. OOP or "Stop Cost", 
						the full amount of a covered service will be paid for by the provided (with the exemption of co-pay). During this point, 
						all benefits covered should be paid for until such time that a benefit cap has been met and from which all financial liabilities 
						will be reverted back to the consumer.</p>
						
					<li><strong>Managed Care Plan Types</strong></li>
						<ul class="paragraph disc">	
							<li><strong>Preferred Provider Organization (PPO)</strong> - In PPO, enrollees are authorized to stay within the network 
							of health care providers. The company makes contracts with a network of health care providers, typically under a 
							fee-for-service agreement. Outside of the network, the enrollees pay for the fees. PPO members pay for the medical 
							services as they were given, instead of paying ahead. The member is being reimbursed by the PPO insurance company with
							the expenses incurred for the services, excluding any co-payments made. In other instances, the insurance company directly
							pays the amount to the physician after the bill was submitted, and the member covers for the co-payment amount he/she
							has made.</li>
							
							<li><strong>Health Management Organization (HMO)</strong> - In HMO, members pay a fixed monthly fee, regardless of the 
							expenses to be incurred for necessary medical services in a particular month. Members are allowed to use the services and
							facilities offered by health care providers within the HMO network only for the cost to be covered. If outside the network,
							members are obliged to pay the bill. HMO has two types namely:</li>
							
							<ol class="paragraph">
								<li><strong><i>Individual Practice Association (IPA)/Network Model HMOs</i></strong> – a type of managed care health 
								insurance plan that contracts a group of physicians and/or solo private practitioners to handle the patients. Usually, 
								participating IPA physicians contract with more than one managed care plan.</li>
								<li><strong><i>Staff/Group Model HMOs</i></strong> - under a staff/group model HMO, physicians are hired either directly 
								by the HMO or by a separate physician group formed to care for the HMO patients.</li>
							</ol>
							
							<li><strong>Point of Service (POS)</strong> - Fundamentally, POS plans function with combined characteristics of HOM 
							and PPO plans. Usually, POS plans function similarly with HMO plans as you are allowed to choose a physician within the 
							network who manages your medical services.  The use of providers outside of the network is allowed, however the beneficiary 
							has to cover for the expenses given. As the name itself suggests, every time the beneficiary needs medical services 
							(the period or “point of service”), he/she has the option to accept care within the network allowing to be managed by the
							primary care physician (PCP) or accept care outside of the network on his/her own terms without a recommendation from 
							the PCP.</li>
						</ul>
					
					<li><strong>Cost Control Methods</strong></li>
						<ul class="paragraph disc">
							<li><strong>Gatekeeping</strong></li>						
							<p class="paragraph"> This is done by requiring referrals or authorization from physicians, acting as managers, for special services such 
							as hospitalization and surgery to ensure the control of costs and services given to recipients.</p>
							
							<li><strong>Capitation </strong></li>
							<p class="paragraph"> Method used to control financial risks, which involves paying for the number of people enrolled rather than the number 
							of services offered.</p>
							
							<li><strong>Withholds</strong></li>						
							<p class="paragraph"> Method used to control financial risks, wherein a percentage of the amount paid for a particular medical service goes 
							into a withhold pool to help compensate for any unforeseen extra volume above the projected expenditures.</p>
							
							<li><strong>Second opinion </strong></li>
							<p class="paragraph"> Under second opinion, the findings and recommendations by the initial doctor must be reviewed and affirmed by a second 
							doctor before treatment is done.</p>
							
							<li><strong>Pre-certification </strong></li>						
							<p class="paragraph"> In pre-certification, before conducting special medical treatment and procedures, the need for such procedures are 
							evaluated and approved by the insurance company in advance.</p>
							
							<li><strong>Pre-admission Testing </strong></li>
							<p class="paragraph"> Reviews and tests are done on the patient prior to admission. This is to avoid longer days the patient has to stay 
							in the hospital.</p>
														
							<li><strong>Concurrent review</strong></li>						
							<p class="paragraph"> A case control nurse does regular evaluations for the authorization of continued or extended in-patient admission 
							and other additional procedures.</p>
							
							<li><strong>Database Profiling </strong></li>
							<p class="paragraph"> Involves the use of graphs and charts, which show the number of services used by every 1,000 patients for each 
							physician or hospital, in identifying whatever unbalanced utilization of services there is.</p>
							
							<li><strong>Intensive case management </strong></li>						
							<p class="paragraph"> Any projected case to amount to more than $10,000 is monitored and managed by a nurse in the insurance company.</p>
							
							<li><strong>Generic Substitution </strong></li>
							<p class="paragraph"> Involves providing less expensive generic drug as prescription to patients over a brand-name drug, taking into 
							account that FDA considers the two as equivalent.</p>
							
							<li><strong>Discharge Planning </strong></li>						
							<p class="paragraph"> Facilitation of immediate home transfer is done by a social worker where he/she meets with the patient and
							patient's family.</p>
							
							<li><strong>Retrospective Review </strong></li>
							<p class="paragraph"> Evaluation is done after discharge of the patient from the hospital to ensure the avoidance of payment accountability 
							for any unnecessary medical services.</p>
							
							<li><strong>Audits </strong></li>
							<p class="paragraph"> Audits are done by a representative from the insurance company to warrant the delivery of all billed services.</p>
						</ul>
						
					<li><strong>Problems Identified in Managed Care Programs</strong></li>
						<ul class="paragraph disc">
							<li>Refusal to pay for emergency room or urgent care.</li>
							<li>Illegal health screening as a prerequisite to membership.</li>
							<li>Refusal to refer to specialists.</li>
							<li>Inadequate diagnostic assessments.</li>
							<li>Failure to inform HMO members of their appeal rights.</li>
							<li>Inadequate government monitoring of the plans to document compliance with federal law.</li>
							<li>Lack of public access.</li>
							<li>Failure to provide minimally mandated Medicare benefits for the seriously ill and disabled, especially for 
							nursing home and home health care.</li>
							<li>Lack of choice in medical care providers.</li>
							<li>Encouraged use of generic medications.</li>
							<li>Early discharge from the hospital.</li>
							<li>Disincentives for physicians to spend adequate time and testing on individual patients.</li>
						</ul>
				</ol>
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